Manual of Surgery Volume Second: Extremities—Head—Neck. Sixth Edition.

by Alexis Thomson; Alexander Miles

The medial epicondyle may be chipped off by a fall on the edge of a table or kerbstone, or it may be forcibly avulsed by traction through the ulnar collateral (internal lateral) ligament, as an accompaniment of dislocation. It is usually displaced downwards and forwards by the flexor muscles attached to it, and may thus come to exert pressure on the ulnar nerve. The fragment may be grasped and made to move on the shaft, producing crepitus. Fibrous union is the usual result.

Up to the age of seventeen or eighteen the epiphysis of the epicondyle may be separated.

Treatment of Fractures in Region of Elbow.—The administration of a general anæsthetic is a valuable aid to accurate reduction and fixation of fractures in this region. Much discussion has taken place as to the best position in which to treat these fractures. In our experience the best approximation of the fragments, as shown by the X-rays, is obtained when the limb is fixed in the position of full flexion with supination. American surgeons favour the position of flexion at a right angle. In the region of the elbow there is a risk of promoting too much callus formation by early and vigorous massage, with the result that the movements of the joint are restricted by locking of the bony projections. This is probably due to bone cells being forced into the surrounding tissues, where they multiply and form new bone on an exaggerated scale.

The supra-condylar fracture is reduced by first extending the elbow to free the lower fragment from the triceps, and then, while making traction through the forearm, manipulating the fragments into position, and finally flexing the elbow to an acute angle and supinating the forearm. In this way the triceps is put upon the stretch and forms a natural posterior splint. A layer of wadding is placed in the bend of the elbow to separate the apposed skin surfaces, the arm placed in a sling so arranged as to support the elbow, and fixed to the side by a body bandage. This position is maintained for three weeks, with daily massage and movement. The last movement to be attempted is that of complete extension. Operative treatment is rarely called for.

Separation of the epiphysis and fracture of the medial epicondyle are treated on the same lines as supra-condylar fracture.

T- or Y-shaped fractures and fractures of the condyles, inasmuch as they implicate the articular surfaces, present greater difficulties in treatment, but they are treated on the same lines as the supra-condylar. In young subjects whose occupation entails free movement of the elbow-joint, it is sometimes advisable to expose the fracture by operation and secure the fragments in position. The details of the operation vary in different cases, and depend upon the line of obliquity of the fracture, and the disposition of the individual fragments, points which may usually be determined by the use of the X-rays. In performing the operation, care must be taken to disturb the periosteum as little as possible, otherwise there may follow excessive formation of new bone.

Operative interference is sometimes necessary for ankylosis or locking of the joint after the fracture is united, or to relieve the ulnar nerve when it is involved in callus. Volkmann's ischæmic contracture is liable to occur after fractures in the region of the elbow from impairment of the blood supply as a result of tight bandaging.

Fracture of the Upper End of the Ulna

Fracture of the olecranon is a comparatively common injury in adults. It usually follows a fall on the flexed elbow, and results from the direct impact, supplemented by the traction of the triceps muscle. In a few cases it has been produced by muscular action alone. The line of fracture may pass through the tip of the process, or through its middle, less frequently through the base. It may be transverse, oblique, T- or V-shaped, but is rarely comminuted or compound.

Clinical Features.—As the fracture almost invariably implicates the articular surface, there is considerable swelling from effusion of blood into the joint. The power of extending the forearm is impaired, and other symptoms of fracture are present. The amount of displacement depends upon the level of the fracture, and the extent to which the aponeurotic expansion of the triceps is torn. As the fracture is usually near the tip, the displacement is comparatively slight, the prolongation of the fibres of insertion of the triceps on to the sides and posterior part of the process holding the small fragment in position; and the fracture may easily escape recognition. When the line of fracture is nearer the base, however, the contraction of the triceps tends to separate the fragments widely ([Fig. 35]), and a distinct gap, which is increased on flexing the elbow, may often be felt between them, and if the elbow is passively extended, the fragments may be brought into apposition, and crepitus elicited.